1. Health Systems Trust Equity Gauge Project
A Partnership between the Health Systems Trust and South African Parliamentarians
Presented by Antoinette Ntuli

2. Objectives To actively monitor equity in health and health care;
Support legislators in utilising equity oriented information and analysing health policy especially with regard to budgeting and resource allocation;
Instil the notion of monitoring equity as a key strategy for the promotion of equity among the media and the general population of South Africa;
Strengthen the accessibility and quality of health data;
Pilot mechanisms whereby disadvantaged communities can utilise information to better advocate for improvements in equity and the meeting of their health needs;
Stimulate responsiveness of legislators, local councillors and service providers to needs identified by their communities.

3. Key Equity Promoting Achievements Since 1994
Equity enshrined in SA constitution
Equity underpins policy development
Unitary Public Health System
Progress with the establishment of a District Health System
Free Primary Health Care and free care for children and pregnant mothers
Upgrading of existing and building of many new clinics
Introduction of community service for newly qualified health personnel

4. Promulgation of Legislation
Health Specific Legislation impacting on:
Medical Schemes
Medicines and related substances
Mental health
Tobacco products
Professional Councils
Laboratories

5. Value for Money? Some International Comparisons
Country
South Africa
Botswana
Thailand
Venezuela
GDP per capita in $
8908
6872
6132
5495
Under 5 mortality per 1000 69 59 30 23

6. Public/Private Divide
Private sector expenditure in 2000 was R3898 per person, almost five times Public sector expenditure of R779 per person
Less than 1 in 5 people have medical aid coverage
Almost 70% of whites having medical aid coverage while less than 10% of Africans have medical aid

7. Health Status in South Africa
Infant mortality rate – 47 for Africans and 11 for whites
Under 5 mortality rate – 64 for Africans and 15 for whites
Provincial as well as racial inequities – stunting twice as prevalent in Mpumalanga where it is 30% as in the Western Cape where it is under 15%

8. Public Sector Expenditure
Per capita expenditure is below R650 in four provinces while it is more than R1200 in the Western Cape.
Sometimes inequity within provinces is even greater, with some districts spending as much as four times more than others per person on health care

9. Trends in Government Financing of Health Care
1992/3 to 1997/8
Growth in Government Financing
Move towards greater provincial equity
Shift of resources to primary health care
1998/9
Reversal of redistribution between provinces
Limited growth in PHC expenditure

10. Health Sector Financing10 20 30 40 50 60 70 80
R billion (1999/00 prices)
Government finances 29 31
Households 23 25 27
Employers 11 12
Total 61 67
1996/97
1997/98
1998/99
Doherty et al Health financing and expenditure in the post-apartheid era.
2002 SAHR

11. Household Spending on Health Care
A survey of households affected by AIDS found that they spent on average a third of their income on healthcare with some rural families spending half of their income on health care.
54% of income of rural households was spent on health care compared to 26% for urban households
From: ‘ A Survey of Households impacted by HIV/AIDS in South Africa: What are the Priority Responses?’

12. Inequity in Provincial Health Spending
250
200
150
100 50
1996/97 -
Rands
1997/98
(50)
(100)
1998/99
(150)
(200)
(250)
(300)
Free State
Gauteng
Mpumalanga
Northern Cape
Eastern Cape
Western Cape
Northern Province
KwaZulu-Natal
Doherty et al Health financing and expenditure in the post-apartheid era.
2002 SAHR

13. Personnel
In Eastern Cape and Northern Province 12 medical practitioners per people as compared with 32 in the Western Cape
Between 60% and 70% of spending is on salaries

14. Health Care Personnel in the Private and Public Sectors 1999
Source: National Health Accounts, The private sector report 2001

15. HIV/AIDS
Difficult to monitor impact of HIV on equity. However it is expected that those areas already most disadvantaged are likely to be more disadvantaged by HIV. This is born out by a recent study among families affected by AIDS:
“There is also evidence that AIDS is making this poverty worse. It is difficult to imagine a response to this epidemic that does not in some way try to alleviate poverty and address the lack of basic services like sanitation”
From ‘A Survey of Households impacted by HIV/AIDS in South Africa: What are the Priority Responses?’

16. Household Sewerage Disposal
Facility Used
Urban
National Urban Data*
Rural
National Rural data* N %
Flush toilet
363
75.5%
42% 50
20.2% 5%
Chemical toilet 4
0.8%
36% 1
0.4% 7%
Pit latrine with vent 30
6.2%
10% 29
11.7%
67%
Other pit latrine 36
7.5% 71
28.7%
Bucket toilet 35
7.3%
11%
14.2% 2%
Non/open veld 9
1.9% 1% 61
24.7%
19%
Communal toilet
0.0%
Total
481
100%
247
From ‘A Survey of Households impacted by HIV/AIDS in South Africa: What are the Priority Responses?’

17. Impact of HIV/AIDS
Estimates as to HIV related bed occupancy in hospitals are as high as 60%
Life expectancy to drop by as much as 20 years by 2010
Social impact may be devastating as a result of the increases poverty, large number of orphans and the effect of loss of life on teachers, nurses etc

18. Recommendations
Stronger equity/backlogs component to formula for allocating global budgets to provinces
Reviewing provincial processes that determine the health allocation within provinces
Further measures to reduce the inequity between the private and public sector. A Social Health Insurance that allows for cross subsidising between the “haves” and the “have nots”

19. Recommendations
Need for a national comprehensive human resource strategy
Attempt to redress urban – rural inequity
Training staff for the level of care that is required

20. Recommendations
In addition to above measures intended to strengthen the Public Health System as a whole there is a need for:
Clarity on the way forward for containing the impact of HIV/AIDS especially with regard to ART and ensuring access to cheap medicines
Seeking opportunities to strengthen public/private partnerships as a vehicle for providing care
Recognising that our response to HIV/AIDS has to be multi-sectoral and include poverty reduction strategies as well as measures designed to improve access to basic facilities, especially sanitation

21. THANK YOU